Image of the Month—Quiz Case

Author Affiliations: Department of Surgery (Drs Meybodi, Eslick, and Cox), and The Whiteley-Martin Research Centre, Sydney Medical School, University of Sydney (Drs Eslick and Cox), Nepean Hospital, New South Wales, Australia.

An 88-year-old woman presented to the emergency department with a 2-day history of gradual-onset, increasing right upper quadrant pain with aggravation on movement and cough. There was no complaint of nausea, vomiting, or change in her bowel habits. Her medical and surgical history included hypertension, gout, hypercholesterolemia, hysterectomy, diverticulosis, and hip replacement complicated by deep vein thrombosis. Physical examination revealed normal vital signs and respiratory and cardiac functions. On abdominal examination, there was no asymmetry or hernia, bowel sounds were present, and a palpable tender mass was detectable in the right upper quadrant, with significant guarding. The Murphy sign was positive and the rest of the abdominal examination was unremarkable. White blood cell count was 13 600/μL (to convert to ×109/L, multiply by 0.001) with a neutrophil count of 11 700/μL, and all liver function test results were normal except for a mildly raised bilirubin level of 1.8 mg/dL (to convert to micromoles per liter, multiply by 17.104). Ultrasonography revealed thickening of the gallbladder wall with multiple calculi (Figure 1). Diameter of the common bile duct and the intrahepatic biliary system were normal. The patient was considered for laparoscopic cholecystectomy, which was done in less than 24 hours of her admission.